This is the area to configure your profile. The information gathered will be used to interface with clients and management of Short-Term-Benefits. Ensuring that correct information is captured will help to receive proper credit for referred clients.
Personal Information
First Name:
Last Name:
Social Security Number:
(format ###-##-####)
Florida License Number:
(Needed if conducting business in Florida)
Access Control Information
Username:
(5-20 characters)
Password:
(8 to 12 characters)
Office Information
Address:
City:
State:
Zip:
Contact Information
Office Phone:
Cell Phone:
Email:
Represented Products
Central United\Manhattan:
TPA Processing:
Who do you represent?
Agency:
Agency POC:
Status:
ACTIVE
Agent ID:
A 2023-12-06 08:46:35
Record Established:
12/06/2023
Last Activity:
12/06/2023
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